Methods of increasing sphincter competence

ABSTRACT

A method of increasing sphincter competence comprising administering to a human in need of treatment an effective amount of a compound having the formula ##STR1## wherein R 1  and R 3  are independently hydrogen, ##STR2## wherein Ar is optionally substituted phenyl; R 2  is selected from the group consisting of pyrrolidino, hexamethyleneimino, and piperidino; or a pharmaceutically acceptable salt of solvate thereof. 
     Also encompassed by the invention is a method of inhibiting urinary or fecal incontinence, or gastroesophageal disease or its symptoms, which includes administering to a human in need thereof an effective amount of a compound of formula 1.

This application claims the benefit of U.S. Provisional Application No.60/010,771, filed Jan. 29, 1996.

BACKGROUND OF THE INVENTION

The current invention relates to the field of medical treatment which ischaracterized by the absence or diminution of control of sphincters ofthe gastrointestinal and urinary tracts, especially, that lack ofcontrol as seen in patients with hormonal deprivation or imbalance,e.g., post-menopausal women.

Sphincters are structures in the body which regulate the flow ofmaterials between the interior and exterior of the body or betweenvarious structures within the body. They function in much the samemanner as a gate or valve in a pipe. Sphincters are composed of rings orflaps of either striated or smooth muscle cells between differentluminal structures: interior, e.g., between the lower esophagus andupper part of the stomach or between the bladder and the posteriorurethra; exterior, e.g., the lower colon and the exterior (the analsphincter). Sphincters composed of striated muscle and controlled by thesympathetic nervous system can, to some extent, be directed by consciousaction, e.g., the external urethral sphincter or the upper esophagealsphincter. Sphincters composed of smooth muscle cells are mainlycontrolled by the parasympathetic nervous system and are not consciouslycontrolled. Smooth muscle sphincters are controlled by internal signalsrelating to the conditions in the luminal areas on either side of thesphincter, e.g., food traveling down the esophagus triggers the loweresophageal sphincter to relax or open to the stomach, or pressure in thebladder signals the sphincter to the posterior urethra to open. Openingof a sphincter is accomplished by the relaxation of the muscle's tone.Normally, most sphincters maintain remain closed or contracted inrelation to their attached luminal structures, thus shutting off theflow of materials. Failure of sphincters to operate properly may be dueto a variety of causes such as an obstruction in the passage, mechanicaldisruption of the passage by trauma or surgery, improper regulation bysignals of the nervous system, or loss of muscle tone due todeterioration of the muscle, often seen in aging or with the loss ofhomeostatic balance of hormones. (For further details see: "Harrison'sPrinciples of Internal Medicine", 9th Ed., Isselbacher, et al.,McGraw-Hill Book Co., NYC, Chap.44, p. 22-3 and Chap. 239, p. 1365-7.)

It is the failure of sphincters due to the loss of hormonal balance andtheir sequelae which are most germane to the current invention. Inparticular, the sphincter failure and resulting conditions germane tothis invention would be: failure of the posterior urethral sphincterleading to urinary incontinence, failure of the anal sphincter leadingto fecal incontinence, and failure of the lower esophageal sphincterleading to gastroesophageal reflux disease.

Urinary incontinence is a common problem with the elderly populationwith at least 15% incidence. The incidence increases to 60% in patientsliving in community care facilities (nursing homes). Although thecondition is not life-threatening, it is a source of both embarrassmentto the patient and a potential problem for the maintenance of properhygienic care for this population. In economic terms, urinaryincontinence represents a substantial cost for the institution providingcare for the aged. There are two major types of urinary incontinencewhich are common to the aged. The first type is stress incontinencewhich the is inability to hold back micturition when a physical stressis placed in the intraabdominal area, e.g., laughing, coughing, orstressful physical activity. The second type is urge incontinence wherethe patient can not delay voiding when the bladder is perceived to befull. Both of these types are common in post-menopausal women,especially parous women with weaken or damaged pelvic muscles andligatures due to child birth. Treatment of this condition may bepalliative such as using absorbent undergarments or in severe cases theuse of alpha adrenergic blockers such as clonidine. However, agents suchas clonidine have substantial cardiovascular side-effects which can makethem not useful for chronic administration for urinary incontinence as asole indication. Much more successful for the chronic treatment urinaryincontinence in post-menopausal women is the use of estrogen hormonereplacement therapy (HRT).

HRT is not usually indicated for the singular use for treatment ofurinary incontinence; however, this is a beneficial effect. However, HRTis plagued with poor patient compliance due to the negativeside-effects, e.g., increased risk of uterine cancer with un-opposedestrogen, negative CNS effects when estrogen is combined withprogestins, bloating, re-initiation of menses, increased breast cancerrisk, etc. Certainly, estrogens are not usually used in males.Therefore, there is a need for better therapies to urinary incontinence,especially in the elderly.

Fecal incontinence occurs in the elderly population in a pattern similarto that seen with urinary incontinence; however, at a much reduced rate.The consequence of patients suffering from this condition can be muchworse than those suffering from urinary incontinence in that hygienebecomes a much more serious problem. More care and economic outlay mustbe used to avoid such problems as infection with this population. Causesfor fecal incontinence appear to be similar to those which cause urinaryincontinence and therefore, the patient population suffering from thismalady is similar, i.e., parous post-menopausal women are the mostcommon suffers. Treatment for this condition is confined to palliativemeasures, such as absorbent undergarments, frequent changes of garments,and frequent bathing. The use of HRT in post-menopausal women as aneffective treatment is not clear, although there is every reason tobelieve that it has the potential for beneficial effects. Perhaps, thelack of clarity is due to the idiosyncratic nature of this condition orthe fact that insufficient data exists because of the relatively fewwomen who will tolerate the negative side-effects of HRT, especiallyolder(70+) post-menopausal women who are the most likely to suffer. Itis clear that better therapy in this area would be of benefit. (Furtherdetails see; "Hormones and Aging", Ed. Timiras et al., CRC Press, BocaRaton Fla., Chap. 8, p.141-142 and references therein.)

GERD is a condition where the contents of the stomach are spilled up(refluxed) into the esophagus. This condition is often due to a failureof the lower esophageal sphincter to close properly. The consequences ofthis reflux are annoying to the patient and potentially serious. Inmilder forms, the patient complains of a burning sensation in theesophagus or heartburn and this often leads to pain, lack of sleep, andloss of productivity. In more serious cases, chronic reflux can lead toulceration of the esophagus leading to surgical intervention or it isthought to be contributory to the development of esophageal cancer.

People of all ages and sexes can suffer from this malady; However, it ismore prevalent in the older population. Anecdotally, women reportchanges (increase or decrease in symptoms) during menstrual cycles,during pregnancy, and during menopause, yet verification of a linkagebetween hormonal levels and GERD remains illusive. It is well known thathormones such as estrogen effect other sphincters of similar physiologyand it is known that estrogens effect stomach motility and other upperGI functions such as gastric emptying. However, other factors causingfailure of the esophageal sphincter, such as herniation of the stomach,hypersensitivity of the esophagus and hyperacidity of the stomach, maycloud a clear understanding of the role of hormones in this condition.

Treatment for GERD consists of mechanical and pharmacologicintervention. Mechanical intervention can be achieved by in severalways, patients who suffer GERD at night can sleep in a more elevatedposition, thus allowing gravity to keep the stomachs contents fromentering the esophagus, obese patients can lose weight, exercise canincrease the tone of the supporting muscles, or surgical interventioncan be used to repair the effected tissues. Pharmacological interventionconsists of lowering the stomachs acidity with antacids or withanticholinergic drugs, such as bethanechol, each or both of these may beeffective, but are problematic for long term use due to negativeside-effects. New agents by themselves or in addition to known,effective agents would improve current therapies for the treatment ofGERD.

The present invention is directed to the discovery that the compounds ofthe present invention, as defined below, increase sphincter competence.

SUMMARY OF THE INVENTION

This invention provides methods of increasing sphincter competencecomprising administering to a human in need thereof an effective amountof a compound of formula I ##STR3## wherein R¹ and R³ are independentlyhydrogen, ##STR4## or wherein Ar is optionally substituted phenyl;

R² is selected from the group consisting of pyrrolidino,hexamethyleneimino, and piperidino; and pharmaceutically acceptablesalts and solvates thereof.

Also encompassed by the invention are methods for inhibiting urinary andfecal incontinence, and gastroesophageal reflux disease.

DETAILED DESCRIPTION OF THE INVENTION

The current invention concerns the discovery that a select group of2-phenyl-3-aroylbenzothiophenes (benzothiophenes), those of formula I,are useful for increasing sphincter competence. The methods of useprovided by this invention are practiced by administering to a human ormammal in need thereof a dose of a compound of formula I or apharmaceutically acceptable salt or solvate thereof, that is effectiveto increase sphincter competence. The present method includes bothmedical therapeutic and/or prophylactic treatment, as appropriate.

The term "inhibit" includes its generally accepted meaning whichincludes prohibiting, preventing restraining, and slowing, stopping, orreversing progression, severity, or a resultant symptom or effect.

The term "effective amount" means the amount of compound necessary toinhibit fecal or urinary incontinence, or gastroesophageal refluxdisease, or increase sphincter competence, as the case may be.

Raloxifene, a compound of this invention is the hydrochloride salt of acompound of formula 1, wherein R¹ and R³ are hydrogen and R² is1-piperidinyl.

Generally, the compound is formulated with common excipients, diluentsor carriers, and compressed into tablets, or formulated as elixirs orsolutions for convenient oral administration, or administered by theintramuscular or intravenous routes. The compounds can be administeredtransdermally, and may be formulated as sustained release dosage formsand the like.

The compounds used in the methods of the current invention can be madeaccording to established procedures, such as those detailed in U.S. Pat.Nos. 4,133,814, 4,418,068, and 4,380,635 all of which are incorporatedby reference herein. In general, the process starts with abenzo[b]thiophene having a 6-hydroxyl group and a 2-(4-hydroxyphenyl)group. The starting compound is protected, alkylated or acylated, anddeprotected to form the formula I compounds. Examples of the preparationof such compounds are provided in the U.S. patents discussed above.Optionally substituted phenyl includes phenyl and phenyl substitutedonce or twice with C₁ -C₆ alkyl, C₁ -C₄ alkoxy, hydroxy, nitro, chloro,fluoro, or tri(chloro or fluoro) methyl.

The compounds used in the methods of this invention formpharmaceutically acceptable acid and base addition salts with a widevariety of organic and inorganic acids and bases and include thephysiologically acceptable salts which are often used in pharmaceuticalchemistry. Such salts are also part of this invention. Typical inorganicacids used to form such salts include hydrochloric, hydrobromic,hydroiodic, nitric, sulfuric, phosphoric, hypophosphoric and the like.Salts derived from organic acids, such as aliphatic mono anddicarboxylic acids, phenyl substituted alkanoic acids, hydroxyalkanoicand hydroxyalkandioic acids, aromatic acids, aliphatic and aromaticsulfonic acids, may also be used. Such pharmaceutically acceptable saltsthus include acetate, phenylacetate, trifluoroacetate, acrylate,ascorbate, benzoate, chlorobenzoate, dinitrobenzoate, hydroxybenzoate,methoxybenzoate, methylbenzoate, o-acetoxybenzoate,naphthalene-2-benzoate, bromide, isobutyrate, phenylbutyrate,β-hydroxybutyrate, butyne-1,4-dioate, hexyne-1,4-dioate, caprate,caprylate, chloride, cinnamate, citrate, formate, fumarate, glycollate,heptanoate, hippurate, lactate, malate, maleate, hydroxymaleate,malonate, mandelate, mesylate, nicotinate, isonicotinate, nitrate,oxalate, phthalate, teraphthalate, phosphate, monohydrogenphosphate,dihydrogenphosphate, metaphosphate, pyrophosphate, propiolate,propionate, phenylpropionate, salicylate, sebacate, succinate, suberate,sulfate, bisulfate, pyrosulfate, sulfite, bisulfite, sulfonate,benzene-sulfonate, p-bromophenylsulfonate, chlorobenzenesulfonate,ethanesulfonate, 2-hydroxyethanesulfonate, methanesulfonate,naphthalene-1-sulfonate, naphthalene-2-sulfonate, p-toluenesulfonate,xylenesulfonate, tartarate, and the like. A preferred salt is thehydrochloride salt.

The pharmaceutically acceptable acid addition salts are typically formedby reacting a compound of formula I with an equimolar or excess amountof acid. The reactants are generally combined in a mutual solvent suchas diethyl ether or benzene. The salt normally precipitates out ofsolution within about one hour to 10 days and can be isolated byfiltration or the solvent can be stripped off by conventional means.

Bases commonly used for formation of salts include ammonium hydroxideand alkali and alkaline earth metal hydroxides, carbonates, as well asaliphatic and primary, secondary and tertiary amines, aliphaticdiamines. Bases especially useful in the preparation of addition saltsinclude ammonium hydroxide, potassium carbonate, methylamine,diethylamine, ethylene diamine and cyclohexylamine.

The pharmaceutically acceptable salts generally have enhanced solubilitycharacteristics compared to the compound from which they are derived,and thus are often more amenable to formulation as liquids or emulsions.

Pharmaceutical formulations can be prepared by procedures known in theart. For example, the compounds can be formulated with commonexcipients, diluents, or carriers, and formed into tablets, capsules,suspensions, powders, and the like. Examples of excipients, diluents,and carriers that are suitable for such formulations include thefollowing: fillers and extenders such as starch, sugars, mannitol, andsilicic derivatives; binding agents such as carboxymethyl cellulose andother cellulose derivatives, alginates, gelatin, and polyvinylpyrrolidone; moisturizing agents such as glycerol; disintegrating agentssuch as calcium carbonate and sodium bicarbonate; agents for retardingdissolution such as paraffin; resorption accelerators such as quaternaryammonium compounds; surface active agents such as cetyl alcohol,glycerol monostearate; adsorptive carriers such as kaolin and bentonite;and lubricants such as talc, calcium and magnesium stearate, and solidpolyethyl glycols.

The compounds can also be formulated as elixirs or solutions forconvenient oral administration or as solutions appropriate forparenteral administration, for instance by intramuscular, subcutaneousor intravenous routes. Additionally, the compounds are well suited toformulation as sustained release dosage forms and the like. Theformulations can be so constituted that they release the activeingredient only or preferably in a particular part of the intestinaltract, possibly over a period of time. The coatings, envelopes, andprotective matrices may be made, for example, from polymeric substancesor waxes.

The particular dosage of a compound of formula I required to increasesphincter competence, inhibit urinary or fecal incontinence, orgastroesophageal reflux disease, according to this invention, willdepend upon the severity and nature of the condition, the route ofadministration, and related factors that will be decided by theattending physician. Generally, accepted and effective daily doses willbe from about 0.1 to about 1000 mg/day, and more typically from about 50to about 200 mg/day. Such dosages will be administered to a subject inneed of treatment from once to about three times each day, or more oftenas needed to effectively increase sphincter competence, or inhibiturinary or fecal incontinence, or gastroesophageal reflux disease.

It is usually preferred to administer a compound of formula I in theform of an acid addition salt, as is customary in the administration ofpharmaceuticals bearing a basic group, such as the piperidino ring. Itis also advantageous to administer such a compound by the oral route.For such purposes the following oral dosage forms are available.

FORMULATIONS

In the formulations which follow, "active ingredient" means a compoundof formula I.

Formulation 1: Gelatin Capsules

Hard gelatin capsules are prepared using the following:

    ______________________________________                                        Ingredient        Quantity (mg/capsule)                                       ______________________________________                                        Active ingredient 0.1-1000                                                    Starch, NF        0-650                                                       Starch flowable powder                                                                          0-650                                                       Silicone fluid 350 centistokes                                                                  0-15                                                        ______________________________________                                    

The ingredients are blended, passed through a No. 45 mesh U.S. sieve,and filled into hard gelatin capsules.

Examples of specific capsule formulations of raloxifene that have beenmade include those shown below:

Formulation 2: Raloxifene Capsule

    ______________________________________                                        Ingredient        Quantity (mg/capsule)                                       ______________________________________                                        Raloxifene        1                                                           Starch, NF        112                                                         Starch flowable powder                                                                          225.3                                                       Silicone fluid 350 centistokes                                                                  1.7                                                         ______________________________________                                    

Formulation 3: Raloxifene Capsule

    ______________________________________                                        Ingredient        Quantity (mg/capsule)                                       ______________________________________                                        Raloxifene        5                                                           Starch, NF        108                                                         Starch flowable powder                                                                          225.3                                                       Silicone fluid 350 centistokes                                                                  1.7                                                         ______________________________________                                    

Formulation 4: Raloxifene Capsule

    ______________________________________                                        Ingredient        Quantity (mg/capsule)                                       ______________________________________                                        Raloxifene        10                                                          Starch, NF        103                                                         Starch flowable powder                                                                          225.3                                                       Silicone fluid 350 centistokes                                                                  1.7                                                         ______________________________________                                    

Formulation 5: Raloxifene Capsule

    ______________________________________                                        Ingredient        Quantity (mg/capsule)                                       ______________________________________                                        Raloxifene        50                                                          Starch, NF        150                                                         Starch flowable powder                                                                          397                                                         Silicone fluid 350 centistokes                                                                  3.0                                                         ______________________________________                                    

The specific formulations above may be changed in compliance with thereasonable variations provided.

A tablet formulation is prepared using the ingredients below:

Formulation 6: Tablets

    ______________________________________                                        Ingredient       Quantity (mg/tablet)                                         ______________________________________                                        Active ingredient                                                                              0.1-1000                                                     Cellulose, microcrystalline                                                                    0-650                                                        Silicon dioxide, fumed                                                                         0-650                                                        Stearate acid    0-15                                                         ______________________________________                                    

The components are blended and compressed to form tablets.

Alternatively, tablets each containing 0.1-1000 mg of active ingredientare made up as follows:

Formulation 7: Tablets

    ______________________________________                                        Ingredient         Quantity (mg/tablet)                                       ______________________________________                                        Active ingredient  0.1-1000                                                   Starch             45                                                         Cellulose, microcrystalline                                                                      35                                                         Polyvinylpyrrolidone                                                                             4                                                          (as 10% solution in water)                                                    Sodium carboxymethyl cellulose                                                                   4.5                                                        Magnesium stearate 0.5                                                        Talc               1                                                          ______________________________________                                    

The active ingredient, starch, and cellulose are passed through a No. 45mesh U.S. sieve and mixed thoroughly. The solution ofpolyvinylpyrrolidone is mixed with the resultant powders which are thenpassed through a No. 14 mesh U.S. sieve. The granules so produced aredried at 50°-60° C. and passed through a No. 18 mesh U.S. sieve. Thesodium carboxymethyl starch, magnesium stearate, and talc, previouslypassed through a No. 60 U.S. sieve, are then added to the granuleswhich, after mixing, are compressed on a tablet machine to yieldtablets.

Suspensions each containing 0.1-1000 mg of medicament per 5 mL dose aremade as follows:

Formulation 8: Suspensions

    ______________________________________                                        Ingredient         Quantity (mg/5 ml)                                         ______________________________________                                        Active ingredient  0.1-1000    mg                                             Sodium carboxymethyl cellulose                                                                   50          mg                                             Syrup              1.25        mg                                             Benzoic acid solution                                                                            0.10        mL                                             Flavor             q.v.                                                       Color              q.v.                                                       Purified water to  5           mL                                             ______________________________________                                    

The medicament is passed through a No. 45 mesh U.S. sieve and mixed withthe sodium carboxymethyl cellulose and syrup to form a smooth paste. Thebenzoic acid solution, flavor, and color are diluted with some of thewater and added, with stirring. Sufficient water is then added toproduce the required volume.

As mentioned previously, compounds of formula I can be used as singleagents or in combination with known, effective agents. Combinationtherapy may be in the form a single dosage entity as illustrated aboveor as separate entities, thus giving the attending physician thegreatest latitude of protocols. If a single entity combination ischosen, other beneficial compounds might include, but not be limited to:0.2 to 2 mg of clonidine for urinary incontinence, 10-50milliequivalents of antacid for GERD (see: "Goodman and Gilman's, ThePharmacologic Basis of Therapeutics, 6th Ed., Macmillan Publishing Co.,NYC, 1980, Chap.42), or 25 mg of bethanecol for GERD. Additionally,these combinations (either as a single entity or as separate entities)may be given at specific time intervals, e.g., after meals or beforesleep, as directed by the attending physician.

The following examples would demonstrate the utility of the currentinvention. These examples are for purposes of illustration and are notmeant to limit the use of this invention in any way.

Urinary Incontinence

Trial 1

Fifty women are selected for entrance to the study. Selection criteriais: 50 to 70 years of age, at least one year post-menopausal, in goodmental and physical health, and suffering from periods (at least onceper week) of stress and/or urge urinary incontinence. Each patient israndomly assigned to either receiving a compound of formula I (treatmentgroup) or placebo (control group). Prior to entry into the study, eachpatient is asked to record incidences of urinary incontinence for aperiod of six weeks. The parameters recorded are the number ofincidents, time of their occurrence, and some measure of their extent,e.g., were only the undergarments soiled?, how many times, did yourincontinence require a change of clothing?, did the bedding get soiled?,could you control the micturation? Did you feel embarrassment oranxiety?, etc.

Twenty-five of the women are given a matched placebo. The othertwenty-five are given a compound of formula I, e.g., a formulatedcapsule containing 60 mg of Raloxifene to be taken once a day. The studycontinues for three months. During the study, the patients record thesame data regarding the number and extent of incidents of urinaryincontinence. At the end of the study, the patient's records areanalyzed. Due to the idiosyncratic nature of this malady, appropriate,multi-variant analysis would used to analyze the data.

Trial 2

This example is same as Trial 1, with the exception that the controlgroup is given a formulation containing a compound of formula I and anestrogen, once a day.

Trial 3

This study is essentially the same as that in Trial 1, with theexception that the treatment group receives in addition a 0.2mg dose ofclonidine taken orally prior to bed time.

Fecal Incontinence

Trial 4

This study is of the same design as that described in Trial 1 with theexception that the treatment period is extended to one year.

GERD

Trial 5

One hundred post-menopausal women (at least one year menopausal prior tothe study initiation) are selected. These patients have the followingentrance criterion: suffer from at least one incident of GERD per weekor four or more incidents per month and be in otherwise good, generalhealth. The diagnosis that these women are suffering from GERD and notsome other malady must be determined by the attending physician. Suchdiagnosis can be made by techniques known in the medical art, e.g., see:"Harrison's Principles of Internal Medicine", ibid., Chap. 289,p.1366-7. Each patient is asked to record the number of incidents ofGERD and their extent, e.g., When did the incidents occur?, Where wasthe pain (heartburn)?, What was the patient doing (bending, sitting,lying down)?, Was any material aspirated?, etc.

Fifty patients (control group) are given a matched placebo to be takenorally once a day. The other fifty patients (treatment group) is given aformulation containing a compound of formula I, e.g., a formulatedtablet containing 60 mg of Raloxifene, to be taken orally once a day.During the study period, the patients record incidents of GERD andcircumstances surrounding these incidents using the same parameters asused in the pre-study period. The study continues for six months. Eachpatient records are analyzed and compared as to the number and extent ofGERD incidents, pre-study versus on-study, using appropriate statisticalanalysis.

Trial 6

This study would be essentially the same as Trial 5 with the exceptionthat the control group receives in addition 25 mg of bethanecol to betaken orally at bed time. The control group in addition receives amatched placebo to be taken orally bed time.

Trial 7

This study is be essentially the same as that of Trial 5 with theexception that the treatment group would, in addition, receive 20 mL ofan antacid such as Maalox® to be taken after each meal and before bedtime.

Utility of the compounds of the invention is illustrated by the positiveimpact displayed by any of the above assays.

We claim:
 1. A method of increasing sphincter competence comprisingadministering to a human in need thereof an effective amount of acompound having the formula ##STR5## wherein R¹ and R³ are independentlyhydrogen, ##STR6## wherein Ar is optionally substituted phenyl; R² isselected from the group consisting of pyrrolidino, hexamethyleneimino,and piperidino; or a pharmaceutically acceptable salt or solvatethereof.
 2. The method of claim 1 wherein said human is female.
 3. Themethod of claim 1 wherein said compound is ##STR7## or its hydrochloridesalt.